Provider Demographics
NPI:1407567209
Name:GOODSHADE CARE SERVICES LLC
Entity type:Organization
Organization Name:GOODSHADE CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GONZAGA
Authorized Official - Middle Name:
Authorized Official - Last Name:MULINDWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-257-7749
Mailing Address - Street 1:4143 E ROCKLEDGE RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6770
Mailing Address - Country:US
Mailing Address - Phone:253-257-7749
Mailing Address - Fax:
Practice Address - Street 1:4143 E ROCKLEDGE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-6770
Practice Address - Country:US
Practice Address - Phone:253-257-7749
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health